Date: First Name: MI: Date of Birth: / / Last Name: Social Security Number: / / Preferred Name: Sex: Gender: Marital Status: Single Married Other

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Ashlynn Alison Wilkinson
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1 PATIENT INFORMATION Date: First Name: MI: Date of Birth: / / Last Name: Social Security Number: / / Preferred Name: Sex: Gender: Home Address: City: State: Zip Code: Marital Status: Single Married Other Home Phone: Cell Phone: address: Employment Status: Employed Full-time Student Part-time Student N/A Is it okay for the therapist / receptionist to leave a message on your cell / home phone regarding future appointments? Please circle one or more. Is it okay for the therapist / receptionist to leave a message on your cell / home phone containing medical information? Please circle one or indicate NO. EMERGENCY CONTACT OR LEGAL GUARDIAN INFORMATION Name: Phone Number(s): Relationship: Spouse Parent Other REFERRING PHYSICIAN INFORMATION Name: Phone Number: REASON FOR TODAY S VISIT In which area of the body is your chief complaint? Head Neck Shoulder Elbow/Wrist/Hand Back Pelvis Hip/Knee/Ankle/Foot Other PLEASE TELL US HOW YOU HEARD ABOUT LIFE IN BALANCE PT & PILATES My Doctor Family/Friend West Seattle Community Shopper Ad Other Another Healthcare Practitioner Internet Search: Google Yelp Facebook Other Insurance Website 1 of 7 pages

2 INSURANCE COMPANY INFORMATION AND/OR CLAIM INFORMATION Personal Insurance Company: Identification Number: Policyholder (if other than patient): Group Number: Relationship to Patient: Date of Birth (of policyholder): / / Phone (of policyholder): SSN: Motor Vehicle Accident Insurance Company: Date of Accident: Adjuster Name: Claim Number: Adjuster Phone Number: Worker s Compensation Insurance Company: Date of Injury: Claim Manager Name: RESPONSIBLE PARTY STATEMENT Claim Number: Phone Number: As the responsible party, I agree that all charges that are not directly paid by my insurance company will be my responsibility. Responsible Party Signature: Date: ASSIGNMENT OF BENEFITS / AUTHORIZATION TO RELEASE MEDICAL INFORMATION / CONSENT TO TREATMENT I hereby assign all medical benefits to which I am entitled to Life in Balance Physical Therapy and Pilates, LLC in the event they file insurance on my behalf. I understand that I am financially responsible for all charges whether or not paid by insurance. In the event my account becomes delinquent and is therefore default of payment, I accept responsibility for the principal amount owing as well as all reasonable costs associated with the collection of this debt. This includes but is not limited to collection service fees, attorney s fees, and all court costs and balances over thirty days old. I hereby authorize said assignee to release all information necessary to secure the payment of said benefits. A copy of this assignment shall be considered as effective and valid as the original. I do hereby consent to such treatment by the authorized personnel of Life in Balance Physical Therapy and Pilates, LLC as may be dictated by prudent medical practice by my illness, injury, or condition. This consent is intended as a waiver of liability for such treatment except acts of negligence. Signature: RECEIPT OF NOTICE OF PATIENT PRIVACY PRACTICES Date: I acknowledge that I have received a copy of the notice of patient privacy practices (page 7), as outlined by the Health Insurance Portability and Accountability Act of Signature: Date: 2 of 7 pages

3 AUTHORIZATION FOR TREATMENT The undersigned hereby authorizes Tricia Yost, DPT, LMP, OCS, Jennifer Howe, MPT, COMT, Megan Sherman, DPT, Lauren Esmailka, DPT, COMPT, Robin Haven, DPT, Elise Becker, DPT Angela Messerli, DPT, and therapists filling in for Life in Balance Physical Therapy and Pilates, LLC to provide physical therapy treatments deemed necessary for my care. I understand that this type of treatment involves the use of touch for diagnosis and treatment and that my therapist will explain this approach to me. AUTHORIZATION FOR CHARGES The undersigned hereby authorizes my insurance benefits to be paid directly to Life in Balance Physical Therapy and Pilates, LLC including health insurance, Personal Injury Protection, Labor and Industries, or other applicable coverage. I fully understand and agree that I am financially responsible for any and all balances due. I also understand that it is my responsibility to determine the physical therapy benefits that apply to my specific insurance plan. This includes, but is not limited to, necessary doctor referrals or prescriptions, deductibles, co-pays, percentage pay out, provider discounts, and yearly coverage. Balances held over 90 days are subject to an interest and records-keeping fee of $5 per month and may be sent to a collection agency. Patients must keep their account balances under $300 to continue treatment. CANCELLATION AND LATE POLICY While you are under the care of a Life in Balance Physical Therapist we will take special care to respect your one-to-one time with the therapist. Each visit is 55 minutes in length and you will be treated solely by a licensed physical therapist. In order to continue to offer such a high quality of care, we ask that you arrive on time for your appointments and give 1 full business day of 24 hours notice in the event that you need to cancel a scheduled appointment. If 24 hours notice is not given, you will be charged a $50 fee. This amount is not covered by insurance. Please note that that if you need to cancel a Monday appointment, you must do so on Friday to avoid the $50 cancellation fee. If you are an L&I patient, your visit may only be 40 minutes as this is the maximum time for which L&I will reimburse. 1 st cancellation without 24-hr notice - no fee, forgiven. 2 nd cancellation without 24-hr notice - $50 fee. 3 rd cancellation without 24-hr notice - $50 fee. Future appointments cancelled. Can call in for same day appointment. I understand that if I am late and/or am not able to give 24 business hours notice cancellation for my appointments that the above cancellation policy applies and is not a fee that is covered by insurance. Signature of Patient or Party Responsible for Bill Date Printed Name 3 of 7 pages

4 BILLING INFORMATION Welcome to Life in Balance. We are excited to work with you and be a part of your healthcare team. Here is some information we would like you to review to improve the understanding of the billing process. Please know we do our best to assist you in understanding your insurance benefits. However, it is your responsibility to know your insurance coverage and benefits. INSURANCE COVERAGE At this time, Life in Balance Physical Therapy and Pilates, LLC is contracted with the following insurance companies: BCBS, Regence, Aetna, Medicare, First Choice Health Network, Cigna, Premera, Regence, Lifewise, L&I, PIP. If you do not see your insurance provider in this list, you will need to call to find out if you have out-of-network benefits with a non-contracted provider. We may verify your insurance benefits and give you the information that we received; however quoted benefits are not a guarantee of payment. Please initial your understanding that it is your responsibility to know your insurance coverage. PATIENT PAYMENTS Co-pays are due at the time of service. Patients with a deductible will pay $ per visit until their deductible is met. Prepaid co-insurance payments are highly recommended. Co-insurance amounts are fully calculated after your insurance has processed the claim. For information regarding this percentage, contact your insurance company. In addition, once the claim is processed, you will receive an EOB (Explanation of Benefits) from your insurance company, detailing the amount paid by insurance and the patient responsibility. Please be aware, bills to patients typically go out the first week of each month. If your claims have not yet processed through insurance, you will not receive a bill for your portion immediately. The claims process typically takes an average of 30 days. Bills will reflect only the amount owed. Your payment is due upon receipt of the bill. Please be advised that unpaid bills, and accounts with balances over $300, may result in Life in Balance discontinuing treatment. CASH PAY Payment is expected at time of service. The rate quoted to you is an already discounted rate. PERSONSAL INJURY PROTECTION (PIP) CLAIMS Please be aware of the monetary limit of your PIP coverage. If it appears you have or will exhaust your PIP, be prepared to provide personal health insurance to cover your visits. If you do not have personal health insurance, please read the 3 rd PARTY section below. THIRD PARTY PIP At this time, we are able to accept 3 rd party PIP on a limited basis. So that we may be able to continue to offer this as a service to our clients, we require a minimum payment of $ per visit at the time of service. At the time of your first visit, we will also need you to acquire a letter of guarantee from your attorney and understand that we will be unable to negotiate fees at the time of the settlement. All outstanding balances will be due in full to Life in Balance Physical Therapy and Pilates, LLC. You always have the option of paying as a cash pay patient for each visit if you would like to reduce the cost of each visit. I have read and understand the billing information listed above. Signature: Date: 4 of 7 pages

5 MEDICAL HISTORY AND SYMPTOM DESCRIPTION Name: Age: Date of Injury/Surgery: Occupation: Job duties or restrictions: Full/Part Time Off Work Y/N Mark areas of symptoms you may experience. Describe your injury or symptoms: Circle today s level of pain: I feel BETTER with WORSE with Please circle the activities you are having DIFFICULTY or discomfort performing as a result of your injury: Sleeping Looking over shoulder Reaching overhead/ behind back/across body Lifting/carrying Grooming Looking up or overhead Stairs: Up/Down Pushing Dressing Sitting Walking Pulling Household Chores Standing Squatting Kneeling Other: Diagnostic Testing: X-Ray MRI CT Scan Other: Prior treatments and results: Have you EVER been diagnosed as having any of the following conditions? In the last 6 months have you experienced? YES NO Cancer, type YES NO Arthritis/DDD YES NO Dizziness YES NO Heart Problems YES NO Asthma YES NO Double Vision YES NO High Blood Pressure YES NO Stomach Ulcers YES NO Fainting YES NO Circulation Problems YES NO Incontinence YES NO Falls/Balance Problems YES NO Diabetes YES NO Osteoporosis YES NO Headaches YES NO Thyroid Problems YES NO Rheumatoid Arthritis YES NO Numbness/Tingling YES NO Kidney Disease YES NO Blood Clots YES NO Nausea/Vomiting YES NO Liver Disease YES NO Depression YES NO Weight Change YES NO Stroke/Brain Injury YES NO Other YES NO Incontinence YES NO Seizures YES NO Night Time Pain YES NO Multiple Sclerosis YES NO Pregnancy YES NO Chemical Dependency (i.e., alcoholism) YES NO Illness/Fever/Infection List pertinent surgeries or medical procedures: MEDICATIONS: What are your goals? I understand the above information represents my health and symptoms. It is accurate to the best of my knowledge. I understand that this information will be used to provide a personalized treatment plan for me. Patient / Guardian Signature: Therapist: 5 of 7 pages

6 NAME DATE REVISED PATIENT FUNCTIONAL SCALE (PFPS) ADPATED FOR LIB Please list at least 3 activities that you are unable to perform or have difficulty performing because of your chief complaint, and please circle the corresponding level of difficulty. 0=FULLY ABLE TO PERFORM 10=UNABLE TO PERFORM ACTIVITY of 7 pages

7 HIPAA FORM -- NOTICE OF PATIENT PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally, are kept properly confidential. This act gives you significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment and healthcare operations. Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. Payment means such activities as obtaining reimbursement for services, confirmation coverage, billing or collection activities, and utilization review. Health care operations include the business aspects of running our practice such as conducting quality assessment and improvement activities, auditing functions, cost management analysis and customer service. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits or services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the office director (privacy officer). The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are however, not required to agree to a required restriction. If we do agree to a restriction we must abide by it unless you agree to it in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. The right to inspect or copy your protected health information. The right to amend your protected health information. The right to receive an accounting of disclosures of protected health information. The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. The notice is effective as of June 10, 2002 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all health information that we maintain. We will post and your may request a written copy of a revised Notice of Privacy practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal written notice, with our office or the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of the notice or the policies and procedures of our office. We will not retaliate against you in any way for filing any such complaint. Please contact us for more information, by asking to speak to our Privacy Officer or for written inquires note Attention Privacy Officer. For more information about HIPAA or to file a complaint you may contact the U. S. Dept of Health and Human Services at the address below: The U.S. Department of Health and Human Services Office of Civil Rights 200 Independence Avenue S.W. Washington, DC Toll Free: 1 (877) of 7 pages

Physical Therapy Services of Ottawa County Patient Registration Form

Physical Therapy Services of Ottawa County Patient Registration Form Personal Information Name Age Sex Date of birth Single Married Widowed Address City State Zip Home phone Cell phone Work phone Email